Monday, April 14, 2014

So what to do about medical care: a modest proposal ...

The problem with medical care is that repeated and draconian interventions by the government have short circuited most of the market mechanisms that would normally lead to the efficient development and delivery of medical services for the consuming public.  These interventions have created powerful fiefdoms with enormous economic incentives to protect the manor houses.  Thus there is no avenue to address a secular progression that will inevitably collapse the finances of the federal and the state governments of the United States.

In addition to the complete hash the government has made, medical care is delivered in a way that intrinsically complicates the operation of market processes:  generally, the one who suffers demands a surcease of sorrow, but specific types and quantities of procedures, medicines, devices and treatments that might grant relief are specified by the patient's agent, a medical professional.  Sadly, that agent, who usually will actually want to attend to the needs of his client, is still subject to crosscurrents (whether from fear of litigation or opportunities born of reimbursement rules) that may distort his incentives to provide the most efficient and effective care.

The real fact that underpins this structural defect is that, beyond the most common maladies (common cold) or injuries (fractured arm),  the one who suffers has been left largely ignorant of how to diagnose his illness and rendered impotent in treating it.  Great systems and institutions have been erected largely to capitalize on this fact.  

Our problems are derived from the progressive impulse to step in and protect the ignorant and impotent by regulating the production of health care services, and thus necessarily restricting their supply, and then when the price goes up, subsidizing demand, and then the price goes up more, putting a lid on it an rationing the consequent shortages.


Suppose that instead of or even in addition to the current mess, the following were done:

(1)  The NIH or a private foundation would spend, say, $100 million to develop a complete course of study and course materials that could be offered one hour per day for each year of K-12.  This course of study would be age appropriate and start with basic sanitation and microbe awareness in Kindergarten through advanced first aid in middle school through disease diagnostics, treatment and rehabilitation in high school.  Or whatever is the maximum program that knowledgeable professionals could develop.  Note that the number of hours of instruction accumulates to almost exactly the number of hours of instruction required to get a Bachelor's degree at most universities.  And all of the hours would be focused on developing practical knowledge about something truly meaningful in every person's life.  

(2)  The NIH would develop a series of qualifying tests that would ascertain the proficiency of each student at various stages of development (say at the end of the sixth, tenth and twelfth grades).  

(3)  The program of study and course materials could be offered free to all school districts and private schools in the nation, as well as online to anyone who wished to participate.  Incentives would be offered to induce the school districts and teachers' unions to enthusiastically participate.  The hour each day spent on the course of study would be in place of some other course, and no additional hours would be put into the school day.  

(4)  At each level of qualification (as determined by the standardized tests), participants in the K-12 and online programs would be able to offer their services to themselves, family, friends and even the public to treat various types of conditions.  The pharmaceutical, medical device and testing industries would be granted sanction to offer the drugs, devices and perform tests prescribed by the qualified so that they could perform the services they were qualified to perform.

(5)  The pharmaceutical, medical device and testing industries would be encouraged to develop and offer treatment programs, tests and devices commensurate with the skill levels of the newly qualified.  Private vendors could be licensed set up shop to offer access to complex diagnostic equipment and advice to those qualified to take it.

Of course, many treatments and controlled substances would remain in the purview of graduates of medical schools.  Heart and brain surgeons would do surgical procedures that use the specialized training and practice required to do heart and brain surgery, oncologists would administer their dangerous poison and  radiation therapies, ophthalmologists would treat eye diseases, and orthopedic surgeons would insert titanium rods to join bones and replace hips and knee joints.  But when the average person is trained to read and understand WebMD, knows how to do advanced first aid, and can monitor, document and track the health progress of themselves and their family and friends, much of what constitutes general/family practice could be either rendered much more efficient or offloaded to qualified self-help practitioners entirely.

The blowback will contend (indirectly, of course, because the anointed seldom say what they mean in public) that the average person cannot hope to learn and comprehend the substance of the information needed to recognize, diagnose, treat or refer people with medical problems. Such doubts must be confronted by the heroic life-saving battlefield deeds of thousands of combat medics trained by the much maligned knuckle-draggers in the Air Force, Army, Navy and (gasp!) the Marine Corps.  The anointed must deny the crucial services performed by paramedics and EMT's every day all over the country.  They must reject the competence of the American citizen in favor of their all-knowing wisdom as proven by their ability to talk.

But even suppose they are right and only twenty percent of students going through K-12 and online training can pass the qualification exams.  Then over the next thirteen years the supply of medical expertise available in society will have been increased by an order of magnitude.  The qualified will be naturally dispersed all over the nation -- roughly in proportion to where people live.  Interestingly, the qualifying tests will also identify a pool of individuals with aptitude and the equivalent of four years of practical medical training coming right out of high school or off the internet.  This could offer feedstock for accelerated training in medical schools to fill up needed specialties.  

The increase in aggregate supply will inevitably and dramatically reduce the price of medical services.  And, if done right, the marginal cost of this program would be negligible so the declining prices would reduce the strain on financing government.

Specialists can further specialize and refine their skills, existing general practitioners can organize the best and brightest of the newly qualified into an efficient business model.  The pharmaceutical, medical device and testing industry can develop more and more sophisticated (i.e., easy to use) drugs, implements and testing kits.  

And best of all, consumers will be more educated and, besides knowing better habits, can be more directly involved in their diagnosis and treatment so that the medical professional is less likely to be susceptible to conflicts of interest.  Also, each individual will be more self-sufficient and sovereign as is envisioned in the American tradition.

1 comment:

  1. Wow, that is so simple really. There is no good argument against this. It is like holding a drivers license, or a CDL or a pilots license.